Endoscopic management for gastrointestinal leaks, perforations, and fistulae: Technical tips and outcomes

Figure 3 Closure of post-endoscopic retrograde cholangiopancreatography duodenal perforation using over-the-scope-clip. A: A large duodenal perforation on the lateral wall at D1-D2 junction with surrounding friable mucosa with bleeding is visualized using a double channel therapeutic scope with an over-the-scope-clip (OTSC) mounted clip; B: One edge of the perforation grasped using the OTSC twin grasper; C: The grasped edge was taken to the opposite end and other edge grasped using the OTSC twin grasper; D: After grasping and approximating both perforation edges, the whole complex was pulled inside the cap; E: After ensuring adequate clip position to ensure optimum margins closure, suction was applied and the OVESCO clip (size 12/6t, OVESCO Endoscopy AG, Tuebingen, Germany) was deployed; F: Post-procedure abdominal X-ray shows the deployed OTSC clip (yellow solid arrow), a naso-jejunal tube (solid orange arrow), subcutaneous emphysema (white asterisk) and air outlining the right peri-nephric area and under surface of liver (dotted white arrow), signifying retroperitoneal duodenal perforation.